Orthopedic and Wound Management
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Transcript of Orthopedic and Wound Management
Orthopedic and Wound Management
Contusions/Hematoma
Contusion: Closed wound in which a
ruptured blood vessel that has hemorrhaged into the surrounding tissues
Blood may form a hematoma if bleeding is sufficient and has been contained
External force or exertional stress
Specific Soft Tissue Emergencies
Contusions/Hematoma
Symptoms: Swelling, discoloration, and
tenderness Populations are risk
Those involved in physical activities, sports, or abusive relationships, and anticoagulant therapy or who have a history of clotting disorders
Specific Soft Tissue Emergencies
Interventions
Rest affected extremity Elevate Splint extremity Lots of education
Contusions and Hematomas
Interventions
Apply cold packs to stimulate vasoconstriction Use for 20 minutes at a time, four
times per day, for the 1st 48-72 hours Wrap cold packs to protect skin
Apply pressure to decrease hemorrhage and swelling Administer pain medication
Contusions and Hematomas
Sprain
The stretching, separation, or tear of a supporting ligament
Strains The separation or tear of a musculotendinous
unit from a bone
Sprains and Strains
Injury may result in:
Pain Inability to weight bear fully Swelling of the affected area
Signs and Symptoms
RICE Rest
Non-weight bearing with crutches Protect from stress;avoid use Splint to decrease movement
Ice Application of ice promotes vasoconstriction and
reduces swelling Know the “rules”
Interventions
RICE Compression
Provides support and helps reduce swelling Elevation
Raise injured part to level of heart for 1st 24 hours
*** Analgesics and anti-inflammatory agents
Interventions
Affects up to 60-80% of population Common causes
Intervertebral disk disease Disk herniation Disk degeneration
Symptoms Will vary Some will radiate
Low back pain
Most back pain is benign Think: what caused the pain?
Must obtain good history What are risk factors for patient?
i.e.- previous back injury, obesity, occupation Infections
Low back pain
An inflammation of a bursa, or sac, that covers
a bony prominence between bones, muscles, and tendons
Common sites Shoulder, elbow, hip, knee, and heel of foot
Bursitis
Must determine
Inflammation or infection
Interventions Rest, ice,
medications, education
Bursitis
Inflammation of the tendons and tendon-
muscle attachments Due to excessive, unaccustomed repetitive
stress May be acute or chronic
Tendinitis
Commonly occurs:
Shoulder- “rotator cuff’ Elbow- “tennis elbow” Knee- “jumper’s elbow” Heel- “achilles tendinitis”
Tendinitis
Interventions
RICE Medications Splints
Tendinitis
Certain fractures and virtually all
dislocations constitute an emergency in the sense that they are a threat to a person’s life or limb
Dislocations Fractures Traumatic amputations Joint effusions Costochondritis
Specific Emergencies of Bony Skeleton
Occurs when the articular surfaces of bones forming a joint are no longer in contact and lose anatomical position
Emergency condition Danger of injury to nerves and blood vessels in the
form of compression, stretching, or ischemia
Dislocations
Emergency condition Good assessment is required
Splint limb Neurovascular assessment Radiographic assessment Reduce ASAP
Dislocations
Break in the continuity of a bone Closed or open Crushed injuries Elderly more prone to fractures Goal
Restore bone alignment and function and reduce disability
Must provide good assessment Review different types of fractures
Fractures
Immobilization MAST trousers Immobilize above and below fracture Splints IV access Elevate
Interventions
Cold packs
If open fracture: IV antibiotics Cover wound with sterile dressing Tetanus
Interventions
Closed reduction
Consent Conscious sedation Monitoring
Fractures
Closed reduction
IV conscious sedation Immobilize after reduction Pain medication Cast care
Fractures
The aim in caring for the patient with an orthopedic
emergency is to restore and preserve function With any trauma DO NOT forget your primary and
secondary assessments! Be familiar with anatomy of the skeletal system
Orthopedic Trauma
Review peripheral nerve assessment Review age-related considerations
Child’s bone structure (immature and is largely cartilaginous
Geriatric: loss of bone minerals and mass Bones more brittle
Orthopedic Trauma
Remain focused on the Identification of life-
threatening injuries Do not get distracted on the amputation Remember your ABCDs
Traumatic Amputations
Amputated part may or may be reimplantable
Excessive bacterial contamination Prolonged period of time Severe degloving or avulsing
Traumatic Amputations
General survey
Stump Amount and type of
contamination Estimated blood loss
Radiographs Stump and amputated part
Traumatic Amputations
Absolute contraindications for replantation
Significant life-threatening injuries Extensive damage to soft tissue injury Inappropriate handling
Traumatic Amputations
Relative contraindications for replantation Avulsion injury Ischemia time greater than 4-6 hours if not cooled Ischemia time greater than 18 hours if cooled Amount and type of contaminants Previous surgery or injury to part
Traumatic Amputations
Interventions for patient
ABCDs Primary and Secondary Assessment Control hemorrhage
Do not use tourniquets or clamps Splint and elevate injured part
Traumatic Amputations
Interventions for patient Do not manipulate distal part Use only saline to clean wound NPO Medications Provide support Transfer to other facility
Traumatic Amputations
Interventions for stump
Gently lift off contaminants Do not rub or clean with soap, water, or
antiseptic solution Wrap in sterile gauze
Traumatic Amputations
Interventions for stump Wrap in sterile gauze
Moisten wrap with saline or RL Do not soak, wrap in, or use any type of water
Place wrapped part in plastic bag and seal Place sealed bag in ice
Do not allow injured part to come in direct contact with ice Do not freeze
Traumatic Amputations
Hemorrhage from fractures Blood loss associated with fractures
Mild to severe Visible or concealed
Estimated blood loss Humerus 1-2 liters Pelvis 1.5-4.5 liters Femur 1-2 liters Hip 1.5-2.5 liters
Life-Threatening Orthopedic Injuries
After a fracture or bone surgery, small fat globules may appear in the blood
Origin of the fat is unknown Fat globules can circulate, causing occlusion of
blood vessels to the brain, kidney, lungs, or other organs
Fat Embolism Syndrome
Long bone fractures and pelvic fractures high
risk for fat embolism syndrome Occur 24 to 48 hours after injury Major cause of morbidity and mortality after
musculoskeletal trauma
Fat Embolism Syndrome
Fat Embolism
Syndrome Signs and Symptoms Tachypnea Tachycardia Hypoxemia Alternation in mental
status
Hemoptysis Thrombocytopenia Fever Petechiae
Interventions
High-flow oxygen Mechanical ventilation IV fluid replacement Vasopressor/inotropic agents IV steroids Surgery Support
Fat Embolism Syndrome
Occurs when compartmental pressures
increase from an internal or an external force Causes
Rigid casts Splints Pneumatic antishock pants
Tends to occur Lower arm Hand Lower leg Foot
Compartment Syndrome
Signs and Symptoms
Pain that is out of proportion to injury Paraesthesia Paralysis Pallor pulse
Compartment Syndrome
Diagnostic procedures
Compartment pressure measurement 10 mm Hg is considered normal Urine for myoglobinuria Enzyme levels
Interventions Remove all forms of external compression Do not impede circulation Avoid ice application Avoid excessive elevation of limb Assist with fracture reduction Analgesics Operative fasciotomy Support
Compartment Syndrome
Primary and secondary assessments Lacerations Abrasions Avulsions Puncture wounds Foreign bodies Missile injuries Human bites Wound-related infections
Wound Management
Lacerations
Result from tearing or sharp cutting Laceration tensile strength is not adequate at
the time of suture removal Application of tape is generally recommended
after suture removal
Wound management
Interventions
ABCDs Control bleeding IV if major blood loss Affected part in position of comfort Shave as little hair as possible
Never shave eyebrows
Wound Management
Interventions
Cleanse and irrigate wound Assist with debridement and repair of
wound Apply splint Immunization Antibiotics Discharge instructions
Use sun block over wound for at least 6 months
Wound Management
Partial thickness denudations of an area of
skin Falls, scrapes, cycle injuries Very painful
Interventions Immunizations Part in position of comfort Cleanse area Medications Avoid direct sunlight for6 months
Abrasions
Full-thickness tissue loss that prevents wound edge approximation
Degloving injuries Full thickness of skin is peeled away Results in devascularization, Surgery required
Interventions Immunizations and antibiotics Elevate part
Avulsions
Interventions Apply sterile, saline gauze Apply steady pressure
Care of amputated tissue Do not allow tissue to come in contact with ice Keep tissue clean, wrap in sterile gauze with saline Seal in container or plastic bag Place bag in bath of ice saline
Avulsions
Tissue is penetrated by sharp or blunt
objects Stepping on nails, tacks, needles, or
broken glass Puncture wounds bleed minimally
Tend to seal off Creates a high risk for infection
Puncture Wounds
Wounds near joints
Risk for bacterial inoculation and sepsis Plantar aspect of foot
Risk for cellulitis, chondritis, and osteomyelitis Plantar puncture wounds through shoes
increase the risk of Pseudomonas infection and osteomyelitis
Puncture Wounds
Local anesthetic Mild analgesia Assist with removal of FB Immunizations Antibiotics Discharge instructions
Puncture Wounds
Include wood, mental, glass, clothing,
fragments from GSWs, pins, needles, fishhooks, thorns
Vegetative foreign bodies (thorns, wood) Highly reactive, lead to infection Should be removed as quickly
as possible
Foreign Bodies
Interventions
Cleanse area around entry site Do not soak part containing wooden
splinters Local anesthesia Mild analgesia Appropriate dressing Immunizations Antibiotics
Foreign Bodies
Stab wounds GSWS Rock from lawn mower Bolt from high power machine Paint and grease guns, staple or nail gun Remain alert to the potential for occult neurovascular
injury Forensic considerations Careful removal of clothing Appropriate handling and disposition of bullets and
weapons
Missile Injuries
Type of instrument Location of wound Estimate of depth inserted Estimate of length of instrument Angle of entrance Direction of force Male or female???
Stab wounds
Location of wound Movement of bullet Tissue characteristics Type of weapon Distance of victim from weapon Characteristics of bullet
Gunshot wounds
Primary/Secondary Assessment Control bleeding Elevation of part Cleanse/irrigate wound Local anesthesia Pain medication Immunizations Antibiotics Provide support Contact proper authorities
Interventions
Lacerations or puncture wounds Increase risk of infection Self-inflicted or person-to-person contact Wound sepsis Clenched-fist injuries: increased risk of joint
penetration and infection
Human Bites
Interventions
Affected part in position of comfort Photographs Cleanse wound with mild antiseptic soap Irrigate with saline Wound debridement Delayed closure is preferred Immunizations Antibiotics Provide support
Human Bites
Common-wound-related infections
Staphylococcus infections Staphylococcus aureus gram-positive bacteria Usually localized abscess Infection may become systemic
Wound–related infections
Pasteurellosis
Pasteurella multocida Necrotizing infection associated with animal
bites Progresses to cellulitis, osteomyelitis, sinusitis,
pleuritis
Wound-related infections
Cat-scratch fever
Unknown etiological organism Associated with cat or dog scratches Regional or local lymphadenitis, self-limiting
Wound-related infections
Wound botulism
Anaerobic Clostridium botulinum Associated with crush injuries or major
trauma Incubation period
4-14 days symptoms
Weakness, blurred vision, difficulty speaking/swallowing, dry mucous membranes, dilated fixed pupils, progressive muscular paralysis
Wound-Related Infections
Gas gangrene
Anaerobic Clostridium perfringens History of intestinal or gallbladder surgery or minor
trauma to old scar containing spores Incubation period 1 day to 6 weeks Symptoms
Thrombosis of local vessels Soft tissue crepitus Severe pain Thin, watery, brown or brown-gray drainage Low-grade fever Tachycardia Anorexia, vomiting, diarrhea, coma
Wound-Related Injuries
Tetanus
Anaerobic Clostridium tetani Found in soil and human and animal
intestines Entry to body through break in skin Incubation period 2 days to several months Prodromal symptoms
Restlessness, headache, muscle spasms Pain (usually in back, neck or face) Low back pain
Wound-Related Infections
Tetanus
Progressive of disease Extreme stiffness, tonic spasms of voluntary
muscles Convulsions Respiratory depression
Wound-Related Infections
Neurotoxin virus acquired from saliva of rabid
animal Major source:
Raccoons, skunks, bats, squirrels, opossums Incubation period: 10 days to several months Children under 12 more susceptible
Rabies
Rabies
Signs and symptoms General malaise Fever Headache Lymphadenitis Photophobia Muscle spasms Coma
Signs and symptoms Muscle spasms Coma Osteomyelitis Abscesses Necrotizing fascitis Osteomyelitis Abscesses
Interventions
Meticulous wound care Topical anesthetic Incision and drainage to relieve pressure and
provide drainage Antibiotics Analgesics
Rabies
Interventions
Current immunizations Prophylactic rabies therapy
Human diploid cell vaccine (HDCV) initially and on days 3, 7, 14, and 28
Supportive care
Rabies